A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Monitor temporal artery temperature.
Restrain the infant's wrists.
Place the infant in a prone position.
Gently clean the suture line with povidone-iodine solution.
The Correct Answer is A
A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will cook foods that are low in fat and carbohydrates.": Children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B. "My child can chew their enzyme medication with meals.": Enzyme medications should not be chewed as they can irritate the oral mucosa; they should be swallowed whole or sprinkled on soft food.
C. "I will give my child stool softeners for constipation." Constipation is a common issue in cystic fibrosis due to thickened intestinal secretions. Stool softeners help prevent this complication.
D. "My child will be excused from physical education class.": Physical activity is encouraged for children with cystic fibrosis to improve lung function.
Correct Answer is D
Explanation
A. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.
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